Health Report: Jene's Case Study Using the SBAR Framework

This health report presents a case study of a patient named Jene, focusing on his hip osteoarthritis. The report utilizes the SBAR (Situation, Background, Assessment, Recommendation) framework to effectively communicate the patient's condition. The Situation outlines the patient's severe hip pain and inability to walk. The Background details Jene's age, diabetic condition, chronic kidney disease, and history of osteoarthritis. The Assessment includes physical and psychological observations, vital signs, and a diagnosis of hip osteoarthritis. The report provides a treatment plan, including rest, pain management strategies, and potential medications or surgery. Finally, recommendations for nutritional supplementation and pain relief are given. This report effectively applies the SBAR framework to provide a clear and structured analysis of the patient's health issues and proposed interventions.

HEALTH REPORT

Table of Contents
SBAR Framework............................................................................................................................1
REFERENCES................................................................................................................................3

This health report covers the case of a patient named as Jene which is mentioned in given
scenario is described below and that is based on SBAR model -
SBAR Framework
The SBAR framework refers to a kind of model which can utilised by team members for
communicating in more effective way to convey desired information with each other.
Situation – I am Petra De Morais working as nurse in word no. 35 for taking care of
patients through providing appropriate medication on time according to instructions of
specialists. It is observed and analysed that, Jene is suffering from high pain in right hip which is
not tolerable and create trouble in walking. This individual is male with an age of 82 years and
face trouble from last two years due to having severe pain in his right hip which results into
unable to walk (Da Costa and et. al., 2017). He also complain that he did not walk for last 2
weeks and feel weak as well as remain on the bed.
Background – I have examined that Jene is complaining about a worse situation due to
intolerable pain in his right hip and it has become more critical in past few weeks. Apart from
this, he is a diabetic patient as well as suffering from chronic kidney disease which has several
symptoms including blood in urine, high blood pressure, fatigue etc. After conducting an
interview, he also states that sometimes his both knees and hips get affected from pain which is
really not tolerable for him. Moreover, he told about his health care issue of osteoarthritis which
get more worse from last few weeks. Meanwhile, osteoarthritis can be described as a joint
inflammation that results into cartilage degeneration which is usually caused due to ageing,
heredity and injury from trauma or disease. Additionally, several symptoms are analysed by me
such as swelling, stiffness, creaking and loss of range of motion in joints. However, Jene is
cleanliness liked person but feeling tired, not able to speech easily and distressed.
Assessment – After conducting an overall procedure of checking up body situation of
Jene, I have analysed that primary survey conclude normal response about his breathing, airway
and circulation. It was also observed that he is not feeling strong and slump in the bed (Jiang and
et. al., 2011). He is looking physically normal with height: 153 cm as well as weight: 85 kg but
his right hip remain painful every time and it is difficult to bear his upper body weight on the
lower part. Besides of this, I have examine that his left hip is free from pain, breathing odour is
fresh and body language is normal. However, psychological appearance states that he is
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cleanliness liked individual due to observing clean dress, body and fresh looking but feeling tired
due to having ache in right hip. Meanwhile, he is looked worried for his pain, not capable to
make easy or clear speech and get distressed. Additionally, there are several vital symptoms are
also analysed such as 36 degree Celsius temperature which may considered as normal as it is
close to the same i.e., 37 ºC. It include 71 per minute pulse rate, 22- 22 per minute respirations,
90- 120 blood pressure and 96 % Oxygen saturation (Sp02).
As per gathered information through analysing symptoms and other other check up
reports, I have analysed that Jene is suffered from Hip osteoarthritis which is a primary level of
this disease. In this case, diagnosis are quite difficult because pain may occur to different parts
such as groin, thigh, buttocks or knee and that ache might be sharp, stabbing, dull (Nho and et.
al., 2013). According to me, treatment plan for reducing problems of hip osteoarthritis is
explained further -
 Rest and joint care
 Utilising a cane to take weight off the left hip of Jene.
 Non- drug pain killer strategies to control the same.
 It include to put efforts for loosing weight.
 Several medications can be provided including acetaminophen (Tylenol), a nonsteroidal
anti-inflammatory drug such as ibuprofen (Advil), or a prescription pain medication.
 At last, hip replacement surgery, complementary and alternative therapies.
The above mentioned strategies are useful in order to solve health issues of Jene for
reducing his problem of hip pain by doing exercise, losing weight and take medicines on time.
Recommendation – I have examined several symptoms and past medical history of Jene.
he is suffering from hip osteoarthritis due which intolerable pain occur in his left buttock. As per
my opinion, nutritional supplementation should be provided in terms of glucosamine and
chondroitin which are helpful in the same cases. Non- narcotic pain killer including
acetaminophen/Tylenol and joint injections like corticosteroid are suitable to reduce disease of
patient (Wright and et. al., 2011). Moreover, there are two types of joint injections such as
Corticosteroid injections and "Viscosupplement" injections in which first one is favourable for
Jene.
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REFERENCES
Books and journals
Da Costa, B. R. and et. al., (2017). Effectiveness of non-steroidal anti-inflammatory drugs for the
treatment of pain in knee and hip osteoarthritis: a network meta-analysis. The Lancet.
390(10090). e21-e33.
Jiang, L. and et. al., (2011). The relationship between body mass index and hip osteoarthritis: a
systematic review and meta-analysis. Joint Bone Spine. 78(2). 150-155.
Nho, S. J. and et. al., (2013). The burden of hip osteoarthritis in the United States: epidemiologic
and economic considerations. JAAOS-Journal of the American Academy of Orthopaedic
Surgeons. 21. S1-S6.
Wright, A. A. and et. al., (2011). Measurement of function in hip osteoarthritis: developing a
standardized approach for physical performance measures. Physiotherapy theory and
practice. 27(4). 253-262.
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